Surgical Techniques in Sports Medicine
1st Edition

10
Repair of Partial-Thickness Articular-Surface Rotator Cuff Tears
John E. Conway MD
History of the Technique
In 1934, Ernest Amory Codman described partial-thickness, articular-surface rotator cuff tears involving the supraspinatus tendon as “rim rents” and expressed his confidence that “these rim rents account for the great majority of sore shoulders.” He also accurately predicted that “these lesions never heal.”1,2 Stephen Snyder later called these defects partial-thickness articular-surface supraspinatus tendon avulsions and coined the term PASTA lesion (Fig. 10-1). Since their original description, considerable attention has been placed on recognizing, understanding, and treating incomplete thickness rotator cuff tears. However, much controversy still exists and simply put, these tears vary widely in presentation. Although the significance of pattern and pathomechanics are now well recognized, the best methods for diagnosis and treatment are yet to be determined.
Several useful classifications for these tears are available. Ellman classified incomplete rotator cuff tears, based on location, as articular surface, bursal surface, or intratendinous and graded these lesions with measurements of both the depth and the area of the defect3 (Table 10-1). The grade classification was later revised to consider the depth of the tear as a percentage of the tendon.4 Snyder proposed a similar classification that assigned a letter for each location and a number for grade in an effort to simplify the description of the lesion. In this system, the grade principally reflects the width of the defect, but also considers the presence of intratendinous delamination (“flap formation”) and retraction.5,6 Unfortunately, these classification systems are best suited to describe tears isolated to the supraspinatus tendon and consider neither the pathomechanics involved nor the significance of anterior/posterior location of the tear as important elements. Several pathomechanisms have been recently proposed for anteriorly located partial thickness tears that involve the upper subscapularis tendon7,8 and Habermeyer et al.7 have proposed a classification system that considers associated pathology. Similarly, the relatively posterior and intratendinous tear pattern commonly reported in young overhead throwing athletes has been recently graded for severity based on depth, width, and delamination in an attempt to provide prognosis and direction for treatment.9
A complete discussion of the pathomechanics of rotator cuff disease would exceed the scope of this article; however, there are several factors contributing to the articular-surface location of some incomplete tears that warrant description.8,10,11,12,13,14,15,16,17,18 The articular surface of the rotator cuff has fewer arterioles and overall less vascularity than the bursa surface. The articular surface has a higher modulus of elasticity and therefore greater stiffness than the bursa surface. Eccentric forces tend to be concentrated more in the articular surface. Bursal surface contact of the rotator cuff against the margin of the acromion may produce tensile undersurface fiber failure. And finally, the articular surface has a less favorable stress strain curve than the bursal surface. The pathomechanics explaining associated intratendinous tears are less clear but probably involve shear within the five-layered architecture of the rotator cuff tendon.15,16,17,19,20,21,22,23
Indications and Contraindications
Débridement of the torn rotator cuff tendon has been recommended in order to stimulate a healing response,24 and some authors have suggested that acromioplasty without tendon repair would provide good surgical outcomes.6,25,26 However, Weber27 reported that, on second-look arthroscopy
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following arthroscopic rotator cuff tear débridement, “healing… was never observed.” Fukuda et al.21 also reported that “apparent evidence of spontaneous repair” of joint sided partial rotator cuff tears “was absent.” It is probable that the continued separation of the torn tendon edges, the poor vascularity of the involved tissues,3,28 and the formation of a synovial covering, both on the visibly exposed segment of the tear and within the intratendinous segment of the tear,23,28,29 precludes any potential for spontaneous healing or healing following simple arthroscopic débridement.23,27
Fig. 10-1. Diagram demonstrating the common tear location for partial-thickness articular-surface supraspinatus tendon avulsion injuries (PASTA lesion). SubS, subscapularis tendon; BT, biceps tendon; SS, supraspinatus tendon; IS, infraspinatus tendon; TM, teres minor tendon. (Modified and reprinted with permission from Conway JE. The management of partial thickness rotator cuff tears in throwers. Oper Tech Sport Med. 2002;10(2):75–85.)
Progression of both the depth of the articular-surface tear and the extent of the intratendinous tear is of considerable concern, and rotator cuff repair may be advisable for the long-term function of the shoulder in some patients.5,27,29,30,31,32,33,34,35 However, the percentage of depth, width, and delamination of the tear that calls for repair, using either open or arthroscopic methods, is controversial.25,27,29,33,36 Because of the risk for both tear progression and less satisfactory surgical outcomes, some authors have suggested that partial thickness rotator cuff tears >50% of the thickness of the tendon should be repaired.3,25,27,30,37,38 Conversely, others have argued that in some patients, particularly overhead athletes, repair potentially increases the morbidity of the procedure and that 75% was a more reasonable depth mitigating for repair.9,39 Finally, while many have suggested that tear completion and bursal side repair are reasonable for small full thickness tears, controversy still exists regarding the efficacy of such treatment for incomplete tears.
Table 10-1 Ellman Classification for Partial Thickness Rotator Cuff Tears
Location Grade Revised grade Area of defect
A: Articular surface 1: <3 mm deep 1: Fraying Base of tear (mm) × Max retraction (mm) = Area in mm2
B: Bursal surface 2: 3–6 mm deep 2: <50% depth
C: Interstitial 3: >6 mm deep 3: >50% depth
Sources: Ellman H. Diagnosis and treatment of incomplete rotator cuff tears. Clin Orthop. 1990;254:64–74; Ellman H, Gartsman GM, Hengst TC, eds. Arthroscopic Shoulder Surgery and Related Procedures. Philadelphia: Lea and Febiger Publishers; 1993.
With such variable presentation, there is certainly no “most appropriate” method to surgically manage all partial thickness articular surface rotator cuff tears, and, of course, articular side repair methods will differ greatly from bursal side repair methods. Many factors affect the treatment decision process, and some of these include the tear size, location, depth, delamination, retraction, and chronicity as well as the tissue quality, bone density, and associated shoulder conditions. The patient’s age, medical condition, smoking history, occupation, avocation, and expectations are also important. Finally, the surgeon’s interest, training, experience, and skill in arthroscopic rotator cuff repair methods must be considered. This article will simply present a modification of a previously described articular side method for the arthroscopic repair of a deep partial thickness articular surface rotator cuff tear involving the supraspinatus tendon.5,9,10,11
Surgical Technique
The patient is positioned in the 30-degree posterior-lateral decubitus position with 20 degrees Fowler’s tilt and the arm is suspended with 10 pounds traction through a shoulder traction device that allows for manual application of shoulder abduction. Following routine shoulder prep, landmarks and portal sites are outlined (Fig. 10-2). During creation of the posterior portal, penetrate the posterior capsule parallel to the glenoid and along the middle of the glenoid rim. A superior or medial portal position may limit visualization during rotator cuff repair. On arthroscopic examination of the glenohumeral joint, observe any
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apparent articular surface “draping” or “pillowing” of either the supraspinatus or infraspinatus tendon, as this may represent occult intratendinous delamination. A probe may be used to define the extent of the intratendinous tear. Also be aware that reduction of the articular surface margin to the tuberosity may increase the relative depth of a small intratendinous tear, creating a need for transtendinous mattress sutures following tendon-to-bone repair.
Fig. 10-2. Photograph of a patient in the lateral decubitus position with the shoulder prepped for arthroscopy. Landmarks and proposed arthroscopic portals are outlined.
With the shoulder suspended in the typical lateral decubitus traction position, both visualization of and access to the torn tendon margins and the greater tuberosity are limited. However, increasing glenohumeral abduction will separate the torn edge of the rotator cuff tendon away from the humerus and provide better exposure of both the tendon and the tuberosity (Fig. 10-3). Unfortunately, even the improved access gained by glenohumeral abduction may be insufficient to allow complete access to these structures. Since suture anchor placement will require a lateral transtendinous portal, this same portal may be used to provide the necessary access to the tendon and tuberosity (Fig. 10-4A,B). An 18-gauge spinal needle placed in a transcutaneous manner through the deepest segment of the tear will identify the site along the lateral margin of the acromion for portal placement. The fibers of both the deltoid and the tendon are then split using a no.11 blade on a no. 7 blade handle producing a 5 to 6 mm portal through the tendon. This step appears to minimize the trauma to the remaining intact fibers of the cuff tendon and a cannula is rarely necessary. By placing an anchor adjacent to the tendon portal and appropriately passing the anchor sutures, the portal will be closed when sutures are tied in the subacromial space.
Limit the extent of tendon débridement to preserve tissue for repair, but remove obviously diseased and poor quality tissue. Optimally, the articular margin of the tear should be directly repaired to the articular margin to the tuberosity and adequate mobility of the tendon edge may be confirmed using an arthroscopic soft tissue grasping instrument placed through the transtendinous portal. However, as there may be considerable loss of the articular surface tendon fibers following débridement, reasonable expectations must be preserved during suture placement. When required, mobility of the supraspinatus tendon is improved by release of both the tendon and the coracohumeral ligament from the base of the coracoid using a combination of biting instruments, shavers, and ablators. Remember to remain aware of the location and vulnerability
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of the suprascapular nerve. When significant intratendinous delamination is recognized, the rotator cuff repair will need to be accomplished in two segments, performing tendon-to-bone repair first. A simple method for intratendinous repair has been previously described.5,37
Fig. 10-3. Diagram of a coronal view of an articular surface tear in the supraspinatus tendon with the glenohumeral joint positioned in both adduction and abduction (inset) demonstrating the improved visualization of the rotator cuff tendon tear and the greater tuberosity with abduction. (Modified and reprinted with permission from Conway JE. The management of partial thickness rotator cuff tears in throwers. Oper Tech Sport Med. 2002; 10(2):75–85.)
Fig. 10-4. Arthroscopic photographs of an articular surface tear in the supraspinatus tendon with the glenohumeral joint positioned in both adduction (A) and abduction (B) demonstrating the improved visualization of the rotator cuff tendon tear and the greater tuberosity with abduction. A transtendinous portal has been created in the lateral segment of the tear allowing introduction of a mechanical shaver for debridement of the tuberosity.
Subacromial impingement is widely considered to be a common cause for articular surface rotator cuff tears. As such, many patients requiring PASTA lesion repair will have either moderate or marked hypertrophy of the subacromial and subdeltoid bursa. Since the repair method described here requires that sutures are passed blindly through the subacromial space and since these same sutures must be safely identified and protected within the subacromial space, it is well advised that the surgeon complete the bursectomy before beginning suture anchor placement. Acromioplasty may be delayed until after tendon repair is completed when hemostasis within the subacromial space is a concern.
Next, the need for either one or two rows of suture anchors is determined, and appropriate suture anchor sites are identified. My preference has been to use two rows of suture anchors when the depth of the tear exceeds 75% (Fig. 10-5). Typically the PASTA lesion tear pattern will be wider along the articular margin, thus requiring a greater number of anchors in the medial row than in the lateral low. However, the lateral anchors should be introduced first as this will allow for the manipulation of sutures without loss of visualization of the tuberosity. As noted above, glenohumeral abduction facilitates visualization of and access to the supraspinatus tendon insertion site onto the greater tuberosity, and this position is certainly useful during both abrasion of the tuberosity and capture of the tendon-to-bone sutures. However, because of the angle to the humeral head and the potential for subchondral penetration, insertion of the suture anchors should be done with minimal glenohumeral abduction (Fig. 10-5).
Select the suture anchor type based on bone quality, site location, and surgeon preference. Bioabsorbable anchors are often preferred in this setting and have several potential advantages over metal anchors, including improved postoperative magnetic resonance imaging (MRI). Test the security of the anchor fixation with longitudinal traction on the
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sutures and confirm that the suture anchor islet remains well beneath the surface of the bone. When the bone is less dense, metal anchors may be more appropriate. Following anchor placement, both limbs of the paired sutures are passed into the glenohumeral joint using a suture retriever through the transtendinous portal and then withdrawn into the anterior cannula. The suture pairs are divided for exposure and capture.
Fig. 10-5. Diagram showing two suture anchors inserted using a trans-tendinous method as described in the text. The lateral row sutures have been passed through the tendon while the medial row sutures exit an anterior cannula. Either straight or curved hollow needles are used to retrieve the sutures through the tendon. (Modified and reprinted with permission from Conway JE. The management of partial thickness rotator cuff tears in throwers. Oper Tech Sport Med. 2002;10(2):75–85.)
The sutures are then captured and placed through the tendon using a modification of a transcutaneous method previously described by Snyder5 for the repair of Snyder classification type A4 anterior articular-surface flap tears. Although many instruments are available for this purpose, I have been most satisfied using one of two hollow needle options. The first option makes use of straight and curved Meniscal Mender II (Instrument Makar, Inc, Okemos, MI) needles and a Shuttle Relay (Linvatec, Inc, Largo, FL). The second option makes use of straight and curved Arthrex MiniLasso Suture Retrievers (Arthrex, Inc, Naples, FL).
The tendon is reduced to the greater tuberosity with a soft tissue grasper, and appropriate suture placement is determined. A hollow suture-passing needle is then passed though both the skin and the tendon into the joint space. The sutures are captured and withdrawn through the tendon using the suture-retrieving loop (Fig. 10-6A,B). Although the individual suture limbs may be passed together or separately, my preference is to pass the sutures through the tendon together in pairs directly above the suture anchor tunnel in an effort to ensure that both the sutures will slide in the anchor islet during suture tying. This option may potentially produce tighter loops.
When the lateral row anchors have been introduced and the paired sets of suture have been passed through the tendon, the steps are repeated for the medial row. The anterior anchors are implanted first in order to more easily manage the suture pairs within the joint. Remember to observe the suture anchor entry angle as subchondral penetration risk is greater for the medial row anchors. For this row, an effort is made to place the suture-passing needles through thick healthy appearing tissue at the margins of the articular surface tear. The suture pairs are separated approximately 1 cm apart across the tendon fibers directly over the suture anchor tunnel and then drawn through the tendon utilizing the method described for the lateral suture row (Fig. 10-7A,B). A soft tissue grasper may be employed to mobilize the tendon to the tuberosity while identifying proper suture placement. After the last sutures are placed, the tendon defect should appear filled with crossing suture pairs (Fig. 10-8). Be aware that it is easy to underestimate the extent of retraction in the posterior margin of the tear, resulting in sutures placed too anterior for anatomic tendon repair. Finally, be certain that reduction of the tendon edge has not created an intratendinous defect that will require concomitant repair.
Externally, the suture pairs exit the skin surrounding the transtendinous portal site and should be separated approximately 1 cm apart (Fig. 10-9). Within the subacromial space, the suture pairs exit the bursal side of the tendon where they are easily identified and separated for tying. My preference has been to tie the lateral suture pairs first.
Tight suture loops and secure knots are paramount to tendon repair success. Although many factors are important, mobilization of the tendon from the scapula, reduction of the torn tendon edge to the tuberosity, accurate alignment of the suture pairs over the suture anchor tunnel, and capture of healthy tendon tissue are essential. In addition, the suture must slide easily through the tendon and the anchor eyelet. To that end, the anchor eyelet must be aligned with the
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direction of the suture passing through the tendon; the suture must pass through the tendon, through the eyelet, and back through the tendon without twisting or crossing; and the suture knot must be tied through the same portal through which the respective anchor was inserted. When two sutures must slide in the same islet, tension must be maintained on the second suture pair to prevent entanglement in the soft tissue or the other suture. Finally, a knot pusher must be used to tighten the loop before locking the knot, and, of course, the surgeon must be able to reliably tie secure arthroscopic knots.
Fig. 10-6. Arthroscopic photographs demonstrating initial suture placement for the lateral suture anchor. A hollow needle placed through the tendon allows introduction of a suture retrieving loop (A). Limbs of both suture pairs and the suture-retrieving loop are captured together with a suture retriever (B) and the sutures are passed through the tendon.
Fig. 10-7. Arthroscopic photographs demonstrating appropriate positioning of a suture passing needle (A) and paired sutures (B) for the first of two medial row suture anchors.
Fig. 10-8. Arthroscopic photograph demonstrating the apparent filling of the rotator cuff tendon defect with suture pairs using the method described in the text. One anchor was place laterally and two were placed medially positioning six sutures for tendon-to-bone repair.
Fig. 10-9. Photograph of six sutures surrounding an arthroscopic portal along the lateral margin of the acromion.
Fig. 10-10. Arthroscopic photographs demonstrating the reduction of the tendon and the sutures over the respective suture anchor tunnel using lateral traction on one suture pair while tying the second suture pair (A). The sutures are exchanged and the second suture pair is similarly tied (B).
Fig. 10-11. Diagram of a coronal view of a repaired articular-surface tear in the supraspinatus tendon using two rows of suture anchors. (Modified and reprinted with permission from Conway JE. The management of partial thickness rotator cuff tears in throwers. Oper Tech Sport Med. 2002;10(2):75–85.)
A simple technique to achieve these elements in the repair process is as follows. Using the method described above, for each suture anchor there are two suture pairs passing together through the tendon. Forcefully retracting both limbs of one suture pair, “the traction suture,” in the far lateral portal, optimally positions the torn tendon for direct reduction to the tuberosity and aligns the suture set to be tied, “the tying suture,” over the respective suture anchor tunnel. The tying suture is then drawn through the transtendinous lateral portal with a suture retriever, which positions this tying suture in line with the suture anchor tunnel. The tying suture is then tied using any reliable method. The suture sets are exchanged in the portals, and the second suture is tied (Fig. 10-10A,B). Both sutures are cut and attention is turned to the next suture pair.
Fig. 10-12. Arthroscopic photographs of the completed repair as view from the bursal surface (A) and the articular surface (B).
After all sutures have been tied, the repair is tested with humeral rotation and glenohumeral abduction (Fig. 10-11). Secure attachment of the tendon to the greater tuberosity should be observed. Finally, return the arthroscope to the glenohumeral joint and similarly observe the repair while rotating the shoulder. The margin of the tear should appear stable and well seated against the tuberosity (Fig. 12A,B). When intratendinous delamination extends medially <2 to 3 cm, transtendinous mattress sutures placed with arthroscopic methods will probably provide adequate fixation for tissue healing.
Supraspinatus outlet impingement symptoms are commonly reported in patients with articular surface rotator cuff tears, and subacromial decompression should be considered in selected cases. Be aware that controversy remains regarding the need for and extent of acromial resection.39,40,41,42,43,44,45,46 Furthermore, outlet impingement is common but rarely the primary cause of shoulder pain in young overhead athletes,40,41 and published treatment methods that included acromioplasty failed to yield good results.39,40,41,46 In some patients, subacromial decompression may be accomplished by simply thinning a hypertrophic coracoacromial ligament with an ablator. However, relative indications for an acromioplasty include the following: coracoacromial ligament abrasion, bursal-surface rotator cuff tear, anterior location of the articular-surface tear, near full-thickness articular-
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surface tear, extensive intratendinous tear, sagittal-oblique MRI demonstrating a prominent anterior edge of the acromion, positive subacromial impingement signs, and age >30 years.
Rehabilitation
An UltraSling shoulder immobilizer (dj Orthopedics, LLC, Vista, CA) is applied in the operating room and worn for 3 weeks. The immobilizer is removed several times a day for gentle passive motion exercises, avoiding horizontal extension and external rotation while the shoulder is abducted. Range of motion is evaluated frequently in the office or in therapy during the first 2 weeks. Early joint stiffness and motion loss are treated by a physical therapist with gentle stretching exercises. No shoulder rotation above 60 degrees of glenohumeral abduction is allowed until 3 weeks following surgery. Glenohumeral abduction in the scapular plane and glenohumeral external rotation without abduction are considered the two most important planes of motion to recover during the first week following surgery.
Lower extremity, trunk, and scapula exercises are begun immediately. At 3 to 4 weeks, passive motion is usually recovered, and a supervised strengthening program for the shoulder begins and continues under the direction of a physical therapist. Progress is made toward recovering internal and external rotation strength with the glenohumeral joint adducted before active abduction exercises begin.
Future Directions
MRI studies and arthroscopic methods may continue to improve, allowing earlier detection and repair of partial thickness rotator cuff tears that exceed 50% depth. Better understanding of the tear morphology and pathomechanisms that lead to tear progression will guide future decisions regarding treatment options.
References
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